The Mindful Hack is a Web log of Denyse O'Leary, co-author of The Spiritual Brain: A neuroscientist's case for the existence of the soul (HarperOne August 2007). The Mindful Hack publishes information of interest on the relationship between the mind and the brain. O'Leary also publishes the Post-Darwinist, which keeps up with the intelligent design controversy.

Enter your search termsSubmit search form

Wednesday, March 25, 2009

Phineas Gage: The evolution of the lecture room psychopath

I was at dinner the other week with a voluble atheist religion professor who, in defense of a materialist view of the human mind, raised the subject of Phineas Gage (1823-1860). Ah yes, the man whose personality changed completely after a horrific accident, a staple of Introductory Psychology.

Anyone who has taken Psychology 101 or read popular neuroscience books has probably heard Gage's story, which upholds the "frontal lobe" theory of personality. (= You are your frontal lobes.)

The story is that in 1848, a tamping rod went through Gage's head and totally changed his personality. He was "no longer Gage." Which demonstrates that the mind and the self are an illusion created by the buzz of neurons in the brain. A textbook case.

I pointed out over dinner that there are good reasons to doubt this story. The prof was, of course, withering. Hundreds and hundreds of psych texts have told Gage's story, he informed me, so how could it be false or questionable?

Well, I have written for newspapers most of my adult life, and one thing I know is this: Printing more copies of any type of information does not make it true. It makes it more widely disseminated.

A distant relative of the Textbook Case sent me an article by University of London historian Zbigniew Kotowicz, "The strange case of Phineas Gage," History of the Human Sciences (Vol. 20 No. 1, pp. 115-131), which offers the story you and six hundred others in Psych 101 may not have heard.

First, let's go over exactly what happened: Gage, 25, was foreman of a gang blowing away rock to lay rail for the Rutland & Burlington Railroad near Cavendish, Vermont. Gage's job was laying explosives. On September 13, 1848, he was momentarily distracted, and the explosive detonated, pushing the tamping rod through his head. The rod was 5.9 kg (13.25 lb.), 1.05 m (over 3.5 ft) long and 44.45 mm (1.75 in) across. As Kotowicz tells the story,

It entered beneath his left cheek, passed behind the eye, pierced the base of the skull, went through the front of the brain, and fell on the ground over 100 feet (30.4 m) away. Covered in blood and brains.

Remarkably, Gage did not lose consciousness. He was able to move and speak. He took about two months to heal. He finished his recovery at his mother's home where, Harlow recounts, he entertained his nephews and nieces with fanciful tales, and looked after farm and domestic animals.

In all, three contemporary reports were written about Gage in professional journals:

1) A report given to a medical audience by his doctor John Harlow, three months after the incident. The famous passage in physician Harlow's account of the changed personality ("no longer Gage") referred to that period and not to the rest of his life. More on that presently.

2) A report by Harvard surgeon Henry Bigelow, who observed Gage over a period of two months somewhat more than a year later and took a life mask of his face (pictured above). According to Bigelow, Gage was calm, "talking with composure and equanimity of the hole in his head." and his behaviour did not fit the profile of a psychopath.

3) A report by Harlow seven years after Gage's death, based on information from his family.

The lecture room legend

And after that? After his death, Gage slowly morphed into the lecture room legend. According to Kotowicz,

... most of the subsequent descriptions of Gage were based on hearsay. Some of them were quite florid; Gage was portrayed as having fits of temper when not getting his own way, as being disinclined to work, as having a reduced libido, as being an aimless drifter and so on. A typical description of him would say that before the accident Gage had been a diligent, reliable, polite and socially adept person: after his accident, he subsequently became uncaring, profane and socially inappropriate in his conduct.

Thus, the damage to Gage’s frontal cortex had resulted in a complete loss of social inhibitions, which often led to inappropriate behaviour.

The documentary evidence

Kotowicz begs to differ:

However, after examining closely the accounts of Phineas Gage as given by the doctors who knew him, Harlow and Bigelow, one must conclude that the supposed psychopathic traits are not evident.

The drastic discntinuity was not so much between Phineas Gage pre- and post-tamping rod but between Phineas Gage (1823-1860) and the lecture room legend.

What we can learn from contemporary accounts of Gage's post-trauma life is this: For a while after the accident, he drifted, and even ended up briefly in P. T. Barnum's freak show, exhibiting himself and the tamping rod. But he then settled down and worked a year and a half in a stable. Later, he went with a friend to Valparaiso in Chile where he cared for horses and drove a coach and six for eight years.

Kotowicz points out the obvious,

Working in stables is not a job for a psychopath. Horses are very sensitive and they require discipline and calm; they have to be attended to regularly, seven days a week, and work begins early.

(They are also apt to bite, kick, rear, and stampede, if startled or abused.)

Of course, Gage had been catastrophically injured, and about twelve years later, the effects caught up with him. By February 1860, back from Chile, he continued to try to work on farms while living with or near his mother, who had moved to San Francisco. But he began to have frequent epileptic convulsions. They worsened, and he died on May 21, 1860. No autopsy was performed, but Harlow later exhumed the body and recovered Gage's skull and the tamping rod.

What no one stopped to think about

Kotowicz's account diverges still further from the lecture room legend:

... what is really amazing is that none of the many who comment on the case seem to have ever stopped for a moment to think what Gage might have looked like after the accident.

A team of researchers using modern computer techniques decided to try to reconstruct his post-accident face, "borrowing" the face of a student whose life mask looks like the one taken of Gage by Bigelow. (A life mask gives a correct image of shape but not of facial mobility.)

The reconstruction they provide would certainly startle a new acquaintance. Kotowicz contends that, to the extent that Gage was unsettled, it was probably mainly due to his horrifying disfigurement and not to psychopathic tendencies:

First he meets his workmates. Their attitude towards him has changed; now they turn their eyes away, they are not the same easygoing fellows; and the girls do not laugh and flirt with him as they did. And if there was some lassie that he was particularly fond of, well . . . all this must be really difficult to take. Someone will look at him, and we can imagine him snapping back, ‘What are you staring at, you bastard?’ And there are also those who are only too ready to give advice, but giving advice to someone in Gage’s predicament is a risky business. Again, we can imagine him telling them to go to hell. Very ungrateful; definitely, to ‘his friends and acquaintances’ he is ‘“no longer Gage”’. It is different at home, at his mother’s, where the final recovery takes place. He entertains his nephews and nieces by making up fantastic stories; they must love Uncle Phineas, and they do not care about his scars. He also grows fond of pets, especially dogs and horses. Animals not only do not care about his scars, they do not even see them. Gage quickly becomes attached to them. But the outside world of adults cannot be ignored. Gage needs to go back to work. And here comes the first tangible blow: he is not wanted back ..."

But he must work; he is a working man.

"As we have seen, Gage finds employment in a stable. Work is hard but it is most likely Gage does not mind, he probably shuns others and keeps to himself (and who in his place wouldn’t?). It may well be that like many before him and many since, he has decided that he is better off in the company of animals than fellow humans. For the rest of his life he will work with horses. After work in the stable, Gage leaves for Chile to set up a coachline. He is ‘occupied in caring for horses, and often driving a coach heavily laden and drawn by six horses’ (ibid.: 415). This means he has strength, dexterity and an excellent relationship with the animals; Gage has evidently mastered his metier.

And, as we have seen, he worked right up to the end.

But, as we have also seen, psych profs didn't need a working man who had independently adapted to his disability; they needed an aimless drifter, so,

... the image of Gage the psychopath has emerged; he is a contemporary construct. Harlow’s words telling us that the ‘equilibrium or balance, so to speak, between his intellectual faculties and animal propensities, seems to have been destroyed’, that he indulged ‘in the grossest profanity’ and that he was ‘no longer Gage’ are now routinely quoted, but nothing else about him is ever mentioned. In the myopic vision of the neurosciences, Phineas Gage has been reduced to a witless psychopath. It seems that the growing commitment to the frontal lobe doctrine of emotions brought Gage to the limelight and shapes how he is described. The psychopath Phineas Gage has now entered scientific folklore; according to a calculation from recent years (Macmillan, 2002: 333) some 60 per cent of psychology textbooks quote it as one of the first cases where personality change occurred after damage to the frontal lobes.

So Kotowicz asks, a century and a half - and hundreds of textbooks - later

Was this a life of a psychopath? Did be behave dismally? One neuroscientist claims that ‘Gage lost something uniquely human, the ability to plan his future as a social being’ (Damasio, 1994: 19). He asks, ‘Did he have a sense of right and wrong?’ (ibid.: 18), which is nothing short of asking whether he had a soul, and he wonders whether Gage was ‘responsible for his acts’ (ibid.). This is a slur on the dead man’s good name. Harlow does not report a single act that Gage should have been ashamed of, let alone made ‘responsible’ for. There is no mention of violence, theft, abuse; not even something as vague as ‘irresponsibility’. There is coherence and dignity in the way Gage dealt with his predicament. He deserves deep respect.

In recent years, the Gage industry has become more nuanced, perhaps in line with a less materialist emphasis on the mind, though many kind readers of this b log doubtless took Intro Psych before that change occurred.

The 19th-century story of Phineas Gage is much quoted in neuroscientific literature as the first recorded case in which personality change (from polite and sociable to psychopathic) occurred after damage to the brain. In this article I contest this interpretation. From a close examination of the story of Gage I have come to conclude that first of all there was nothing psychopathic in Gage’s behavior and that changes in his life are more coherently explained by seeing them as his way of dealing with disfigurement that he suffered after the accident. This is not just a matter of reinterpreting a case. The way Gage has been presented and discussed in neuroscientific literature suggests that the new paradigm of neuroscientifically oriented psychiatry may lead to an erosion of clinical knowledge.